A concentração de angiopoetina 2 em crianças desenvolvendo displasia broncopulmonar: uma atenuação pela dexametasona

1. A concentração de angiopoetina 2 em crianças desenvolvendo displasia broncopulmonar: uma atenuação pela dexametasona Escola Superior de Ciências da Saúde (ESCS)/SES/DF Clube de Revista Brenda Carla Lima Silva Janayana Oliveira Almeida Pablo Almeida Rocha Orientação: Dr Paulo R. Margotto www.paulomargotto.com.br 26/2//2008 – Hospital Regional da Asa Sul/SES/DF

2. Angiopoietin 2 concentrations in infants developing bronchopulmonary dysplasia: attenuation by dexamethasone ZH Aghai1, S Faqiri1, JG Saslow1, T Nakhla1, S Farhath1, A Kumar1, R Eydelman2, L Strande2, G Stahl1, P Leone2 and V Bhandari3 1Department of Pediatrics, Cooper University Hospital Robert Wood Johnson Medical School, UMDNJ Camden, NJ, USA; 2Department of Surgery, Cooper University Hospital Robert Wood Johnson Medical School, UMDNJ Camden, NJ, USA and 3Division of Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA J Perinatol 2008; 28: 149-155

3. Introdução • DBP: importante causa de morbimortalidade em prematuros • Importante sequela: hiperreatividade de vias aéreas e asma • Incidência sem mudanças significativas na ultima década • Patogenia complexa: injúrias (infecção intra-útero, por ventilação mecânica, hiperoxia) desencadeiam cascata inflamatória, que age em células imaturas do pulmão

4. Introdução • Angiopoetina2: • Regulariza angiogênese e integridade vascular • Na inflamação: citocinas induzem a expressão de Ang2 nos sítios de ativação endotelial • Sua liberação: rápida desestabilização do endotélio, disparando a resposta inflamatória

5. Incrementa resposta inflamatória e desencadeia morte de células pulmonares expostas à hiperoxia!!!

6. Objetivo • Medir Ang2 na amostra de Aspirado Traqueal (TA) e associar ao desenvolvimento de DBP ou morte em prematuros ventilados • Avaliar o efeito do uso de dexametasona na concentração de Ang2

7. Métodos • População: • 39 leitos de UTI Neo do Cooper University Hospital in Camden, NJ • Março/2003 a outubro/2006 • Aprovado por comitê de ética; consentimento livre e esclarecido • Eleitos: IG< 32 sem e necessidade de VM • DBP = O2 por IGPC>=36 sem

8. Métodos • Coleta da amostra: • Dias 1, 3, 5 e 7, na vigência de VM • Amostra adicional: antes e 48h a 72h depois de iniciar corticoterapia • Corticóide: 9 dias (0,3/0,2/0,1 mg/kg/dia) • Instilação de 0,5ml de SF no tubo, e sucção de resíduo após 3 ventilações • Processamento em 30 min em laboratório: centrifugação

9. Métodos • Teste de ang2 • Medido por Kit ELISA • Detecção de 1,2 a 21,3 pg/ml (média:8,3) • Sem reatividade cruzada com Ang1, Tie2 ou fator de crescimento endotelial • Teste de proteína: • Concentração de proteína foi medida em cada amostra para correção da diluição durante a lavagem

10. Métodos • Análise estatística • SigmaStat 3,1 (pacote estatístico do Windows) • Valor mínimo de significância = 12 (alfa=0,05) • Dados continuos:Teste de T-Student, Mann-Witney, U-test, • Dados categóricos: X2 ou Fisher • Análise da curva: MedCalc • Significância: P<= 0,05

11. Resultados • Foram coletados 151 amostras de 60 prematuros ventilados; • 12 crianças não apresentaram DBP ( IG: 26,5 +/- 2,1 semanas e peso ao nascer: 913 +/- 230g); • 32 crianças desenvolveram DBP ( IG: 25,8 +/-1,4 semanas e peso ao nascer: 768 +/- 157g); • 16 crianças foram a óbito antes de 36 semanas da IGpc ( IG: 24,5 +/- 1,1 semanas e peso ao nascer: 710 +/- 143g)

12. Resultados • Na primeira semana de vida, a concentração de angiopoetina 2 foi significativamente baixa nas crianças sem DBP (157, 16 e 218 pg/mg), quando comparada aos que desenvolveram DBP (234, 138 e 338pg/mg, P= 0,03) ou aos que morreram (234, 157 e 347 pg/mg, P= 0,017);

13. Resultados • 26 crianças (Peso ao nascer: 719 +/- 136g e IG: 25,1 +/-1,3 semanas) , receberam terapia com corticóide – 27 doses de Dexametasona; • a concentração de angiopoetina 2 antes de iniciar a corticoterapia foi 202, 137 e 278 pg/mg; • esta concentração foi significativamente diminuída após o fim da terapia : 144, 0 e 224 pg/mg (p=0,007);

14. Resultados Características dos grupos

15. Discussão • Vários estudos utilizam vários marcadores para a identificação de DBP em aspirados traqueais (AT) de prematuros ventilados (TNFα, IL1, IL6, etc), com vários deles sendo propostos para o diagnóstico da DBP, mas os resultados foram inconclusivos por uso de diferentes metodologias e concentração-dependentes!

16. Discussão • O que os estudos mostram: • IL1β, IL6, IL8, VEGF, fator de crescimento de queratinócitos, proteína quimiotáxica de monócitos estão relacionadas a injúria dos pulmões, in vitro

17. Discussão • A maioria dos estudos teve um n diminuído, com coleta de AT em períodos diferentes, sem padronização, com definições variáveis de DBP • Aspirado traqueal X lavagem broncoalveolar • Padronização do aspirado traqueal

18. Discussão • Neste estudo os valores de Ang2 foram padronizadas pela correção da diluição... Mas mesmo sem usar o método para corrigir a diluição, os resultados se mostraram significativos!!

19. Discussão Concentração de Ang2 (corrigida) em aspirados traqueais

20. Discussão Concentração de Ang2 (não-corrigida) em aspirados traqueais

21. Discussão Concentração de Ang2 em ATs nos dias 1, 3, 5 e 7

22. Discussão • Pontos fortes do estudo: • Grande coorte • Múltiplas amostras em tempos clínicos relevantes • DBP definida a 36 semanas de IGpc

23. Discussão • Dexametasona foi associada com decréscimo significativo das concentrações de Ang2 (com ou sem diluição), e com ou sem DBP • Pequeno n (apenas 5 sem DBP)

24. Discussão Concentração de Ang2 (corrigida) antes e depois da Dex

25. Conclusão • Concentração de Ang2 está significativamente aumentada em bebês, na primeira semana de vida, que tiveram uma intercorrência (DBP e/ou morte) • A terapia com dexametasona foi associada com uma diminuição nos valores de Ang2 nos aspirados traqueais

26. Abstract Objectives: To study the association between angiopoietin 2 (Ang2) concentrations in tracheal aspirates (TAs) and adverse outcome (bronchopulmonary dysplasia (BPD)/death) in ventilated premature infants (VPIs) and modulation of Ang2 concentrations with dexamethasone (Dex) use. Study Design: Serial TA samples were collected on days 1, 3, 5 and 7, and Ang2 concentrations were measured. Ang2 TA concentrations were compared prior to and after 48 to 72 h of using Dex. Result: A total of 151 TA samples were collected from 60 VPIs. BPD was defined as the oxygen requirement at 36 weeks postmenstrual age (PMA). Twelve infants (mean s.d.) (gestational age (GA) 26.5 2.1 weeks, birth weight (BW) 913 230 g) had no BPD, 32 infants (GA 25.8 1.4 weeks, BW 768 157 g) developed BPD and 16 infants (GA 24.5 1.1 weeks, BW 710 143 g) died before 36 weeks PMA. Ang2 concentrations were significantly lower in infants with no BPD (median, 25th and 75th percentile) (157, 16 and 218 pg mg-1) compared with those who developed BPD (234, 138 and 338 pg mg-1, P=0.03) or BPD and/or death (234, 157 and 347 pg mg-1, P=0.017), in the first week of life. Twenty-six VPIs (BW 719 136 g, GA 25.1 1.3 weeks) received 27 courses of Dex. Ang2 concentrations before starting Dex were 202, 137 and 278 pg mg-1 and significantly decreased to 144, 0 and 224 pg mg-1 after therapy (P=0.007). Conclusions: Higher Ang2 concentrations in TAs are associated with the development of BPD or death in VPIs.Dex use suppressed Ang2 concentrations. Keywords: cytokines, premature, newborns, lung, inflammation, hyperoxia, tracheal aspirates

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34. Obrigado! Ddos Pablo, Brenda e Janayana e Dr. Paulo R. Margotto